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SPINE IMPAIRMENTSEverything you wanted to know about
rating the spine, but were afraid to ask…
Presented byJoe Carranza & Annalisa Faina
DWC Conference 2013
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Presentation Overview
1) Why radiculopathy is important
2) Choice of rating method
‐ DRE Method
‐ ROM method
3) Spinal cord injuries
4) Pain
5) Almaraz/Guzman ratings
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Spine Impairments
Regions of the Spine
• Cervical
• Thoracic
• Lumbar
Spine is rated regionally
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Radiculopathy
Alteration of function of nerve root
Important for
• Choice of rating method
• Placement in DRE category
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Radiculopathy
Verified radiculopathy
• Clinical findings in dermatome pattern
• Corresponding imaging studies
Unverified radiculopathy
No corresponding imaging studies
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Choice of Method
Two Standard Methods
• DRE
• ROM
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DRE (Diagnosis Related Estimate)
Criteria
• Single level involvement
• Corticospine injury
The DRE method is the principle methodology used to evaluate an individual who has had a distinct injury. (pg. 379)
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DRE Categories DRE I Subjective findings only
DRE II Muscle guarding,/asymmetric ROM
Unverified radiculopathy
Resolved verified radiculopathy
DRE III Unresolved verified radiculopathy
Spine surgery one level
DRE IV Alteration motion segment integrity (fusion)
Bilateral or multi‐level radiculopathy (cervical thoracic spines)
DRE V Alteration motion segment integrity
With radiculopathy
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DRE (Diagnosis Related Estimate)
Physicians should:•Determine clinical findings
•Assess diagnostic test results
•Determine appropriate method
•Place in DRE category
•Choose WP impairment within range (ADL)
•Provide rationale for findings
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Example #1
• Carpenter, 28 years old
• Cervical spine injury
• C 5-6 herniation with radiculopathy resolved
• C 6-7 protrusion
• No difficulties with ADLs
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Example #1
DRE or ROM method?
DRE – one level of radiculopathy
If DRE, which category?
Cervical spine, DRE II (5-8 WP)
- resolved radiculopathy
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Example #1
Physician provides WP impairment within DRE category
5 WP (no difficulty ADL)
Rating
15.01.01.00 – 5 – [5]6 – 380H – 8 – 7 PD
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ROM Method
Criteria
•Multi-level or bilateral radiculopathy
•Multi-level surgery
•Multi-level AOMSI
•Multi-level fracture
•Recurrent radiculopathy
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ROM Method
Three Components of Impairment
1) Diagnosis (Table 15-7)
2) Range of motion measurements (Tables15-8 through 15-14)
3) Nerve Deficit
• Sensory deficit (Tables15-15, 15-17, 15-18)
• Motor deficit (Tables15-16, 15-17, 15-18)
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Example #2
• Scout, Professional Sports, 59 years old
• L3-5 fusion with L3 nerve root deficit
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Example #2
• Which method should be used?
ROM
Two level fusion
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Example #2
• Factors of Impairment
• Two level fusion
• ROM: S: 15-0-30 (sacral 30 degrees) F: 10-0-10
• L3 Sensory, Grade 4, 25%
• L3 Motor, Grade 4, 25%
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Diagnostic ComponentLumbar
Diagnosis 12 + 1 = 13 WP
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ROM Component
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ROM Component
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Spine ROM Problem
ROM (Tables 15‐8, 15‐9)
• Forward flexion 30 degrees = 4 WP
• Extension 10 degrees = 3 WP
• Lt lateral bending 10 degrees = 3 WP
• Rt lateral bending 10 degrees = 3 WP
• Total 13 WP
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Spine ROM Problem
Combine diagnosis and ROM impairment
13 C 13 = 24 WP
Adjust for disability
15.03.02.04 – 24 – [5]31 – 251E – 29 – 36 PD (A)
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Neurologic Component
Sensory = 5 x 25% = 1 LE x .4 = 0 WP
Motor = 20 x 25% = 5 LE x .4 = 2 WP
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Example # 2
Motor nerve deficit
15.03.02.06 – 2 – [5]3 – 251E – 3 – 4 PD
Combining Diag/ROM and Nerve Deficit
36 C 4 = 39 Final PD
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When both DRE and ROM Apply
In the small number of instances in which the ROM and DRE methods can both be used, evaluate the individual with both methods and award the higher rating. (pg. 380)
Multi-level or bilateral radiculopathy
In cervical or thoracic spine
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Can ROM Method be used twice?
If more than one spinal region is impairment and both regions meet the criteria for ROM, then only one can be rated using ROM and the other using DRE. (pg. 381)
ROM method is used only in one spine region per injury in standard AMA Guides rating
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Example #3
• Jockey, 34 years old
• Cervical spine injury
• Discectomy C5-6
• Continued bilateral radiculopathy
• Difficulty with most ADLs
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Example #3
• Physician chooses DRE Method
• Physician selects DRE III category – 15 WP
• DRE Rating
15.01.01.00 – 15 – [5]19 – 590J – 28 – 27 PD
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Example #3
• DEU Annotation on Rating
• Higher of ROM or DRE IV category (25‐28 WP) may be applicable.
• What would you do?
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Corticospine Injury
• Spinal cord injury
• DRE method
• Combine with Table 15‐6 impairments
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Corticospinal Tract Involvement
Physician should:
• Identify level of cord involvement
• Determine the degree of residual function
• Use appropriate DRE category
• Rate applicable Table 15-6 impairments
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Corticospine Injury
Table 15-6 Impairments•One Upper extremity
•Two Upper extremities
•Station and Gait Disorders
•Bladder Impairment
•Anorectal Impairment
•Sexual Impairment
•Impairment of Respiration
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Example #4
• Fish and Game Warden, 45 years old
• Spinal cord injury at L3 resulting in DRE III = 13 WP
• Necessity for use of wheelchair, Class 4 = 55 WP
• No voluntary control of bladder or bowel
– Bladder, Class 4 = 50 WP
– Anorectal, Class 3 = 50 WP
• No sexual function, Class 3 = 20 WP
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Example #4
DRE III Rating
15.03.01.00 – 13 – [5]17 – 490I – 23 – 24 PD (A)
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Example #4
15.04.03.00 – 55 – [5]70 – 490I – 77 – 79 PD
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Example #4
15.04.04.00 – 50 – [2]57 – 490H – 63 – 65 PD
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Example #4
15.04.05.00 – 50 – [2]57 – 490H – 63 – 65 PD15.04.06.00 – 20 – [2]23 – 490F – 23 – 24 PD
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Example #4
15.03.01.00 – 13 – [5]17 – 490I – 23 – 24 PD (A)15.04.03.00 – 55 – [5]70 – 490I – 77 – 79 PD (A)15.04.04.00 – 50 – [2]57 – 490H – 63 – 65 PD (A)15.04.05.00 – 50 – [2]57 – 490H – 63 – 65 PD (A)15.04.06.00 – 20 – [2]23 – 490F – 23 – 24 PD (A)
79 C 65 = 9393 C 65 = 9898 C 24 = 9898 C 24 = 98 Final PD
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Example #4
• LC 4662
• Paralysis = 100%
• Confined to wheelchair
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Spine Rating Pitfalls
• Incorrect rating method
• Not providing WP impairment within DRE category
• Not providing Sacral (hip) flexion angle
• Not providing diagnostic component for ROM method
• Not addressing motor/sensory deficit for ROM method
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Pain
Pain is defined in the AMA Guides by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
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Pain
Impairment ratings in the Guides already have accounted for commonly associated pain, including that which may be experienced in areas distant to the specific site of pathology.
i.e. cervical spine with radiating pain down arm, the arm pain has been accounted for in the cervical spine impairment.
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Pain
• Chapter 18, AMA Guides, 5th edition
• 2005 PDRS, page 1-12
• Maximum allowance for pain resulting from a single injury is 3 WP regardless of number of impairments resulting from injury.
• Physician needs to use their clinical judgment as to what constitutes normal or expected pain.
• Physician must provide rationale for pain.
• Physician must assign 1, 2 or 3 WP for pain if applicable.
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Almaraz/Guzman
• Physician may use four corners of AMA Guides
• Accurate rating
• Rationale
• DEU will provide both standard AMA Guides rating and Almaraz/Guzman rating
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Almaraz/Guzman
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Almaraz/Guzman Example
• Use of Table 6-9 – Class 2 19 WP
• DEU Rating
• Rating per Almaraz case
• 15.03.01.99 – 19 – [5]24 – 491H – 29 – 25 PD
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Use of Table 6‐9
Strengths
• Within 4 corners
• Physician expert opinion
Weaknesses
• Not typically used to rate spine
• Criteria for category not met
• Possible introduction of work restriction
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SB 863 and the Spine
• For DOI after 1/1/2013,
• No longer use FEC rank [5],
• Use of 1.4 modifier instead
• No longer rate add-ons for sleep, sex or psyche
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Physician Responsibilities
• Clinical and diagnostic findings
• Choice of method
• Provide impairments for appropriate method
• Almaraz/Guzman if applicable
• Apportionment
• Always have rationale
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Parties Responsibilities
• Identify possible rating issues
• Read DEU annotations on ratings
• Clarify with physician
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Redding California
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